Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia

We report three cases of sustained monomorphic ventricular tachycardia (VT) in the setting of coronary artery disease, resistant to beta-blockers in two patients and to amiodarone in all, successfully terminated by low doses of intravenous (IV) epinephrine. VT was the first manifestation of coronary artery disease in one patient, whereas the other two patients had a previous history of myocardial infarction and were recipients of an implantable cardioverter-defibrillator (ICD). One of these two patients experienced an arrhythmic storm. All had hemodynamic instability at the time of epinephrine administration. A single slow administration of IV epinephrine (0.5 to 1 mg administered over 30 to 60 s) restored sinus rhythm after 30-90 s with only minor side effects. In the ICD patient with recurrent VT and several cardioversions due to transformation of VT to ventricular fibrillation, epinephrine injection led to the avoidance of further shocks. Although potentially harmful, low doses of IV epinephrine used alone or in combination with beta-blocker treatment and electrical cardioversion may be an alternative effective therapy for sustained monomorphic VT refractory to amiodarone. The role of epinephrine in the termination of VT should be studied further, especially in patients pre-treated with amiodarone in combination with beta-blockers.